Comparative diagnostic performance of advanced endoscopic techniques in suspected sarcoidosis: A systematic review and network meta-analysis

BACKGROUND: While various endoscopic techniques are used for minimally invasive tissue sampling in suspected sarcoidosis, comprehensive evidence comparing their diagnostic efficacy is limited, and the optimal approach remains unclear. RESEARCH QUESTION: Which endoscopic technique provides the greatest diagnostic advantage for sarcoidosis? STUDY DESIGN AND METHODS: We systematically searched 3 databases for studies published up to 22 April 2025. A network meta-analysis was conducted within a Bayesian framework, with diagnostic yield as the primary outcome. RESULTS: A total of 35 studies were included. Compared to TBLB, both EBUS-guided intranodal forceps biopsy (EBUS-IFB) (RR 3.50, 2.14-5.84) and EBUS-guided transbronchial mediastinal cryobiopsy (EBUS-TMC) (RR 3.52, 1.97-6.48) showed higher diagnostic yield. SUCRA rankings placed EBUS-IFB (0.912) and EBUS-TMC (0.910) at the top, followed by EBUS-guided core needle biopsy (EBUS-CNB) (0.587), EUS-FNA (0.582), and EBUS-TBNA (0.560), EUS-B-FNA (0.498). Conventional techniques, including cTBNA (0.279), TBLB (0.168), and EBB (0.001), ranked lowest. All procedures had a favourable safety profile. CONCLUSIONS: In centres with appropriate expertise, EBUS-IFB and EBUS-TMC may offer superior diagnostic performance for sarcoidosis. However, given the low certainty of evidence, these conclusions should be interpreted with caution. Clinical decisions should be individualised, considering the patient's condition when determining the final diagnostic strategy.